TDLC - Confidential Insurance Client Intake Form

General Information
Gender: Male | Female
Patient (child's) Name
Child's Date of Birth
Street Address
City, State, Zip
Home Phone
E-Mail
Parent's Name
Parent's Phone
Insured's Name
Policy Holder Date of Birth
Check the services you require:
ABA Services | Social Skills | Speech Therapy | Parent Training | Counseling Services | Occupational Therapy
Diagnosis - VERY IMPORTANT! - Check all that apply
Autism Spectrum Disorder | PDD-NOS | Seizure Disorder
Encephalopathy | Speech Delay | Receptive/Expressive Language Disorder
Other Disorders
Primary Doctor/Physician's Name Phone Number
I agree to provide medical release form. (Download Form Here)
Insurance Information
Insurance Company
Policy Number
Insurance Address/P.O.
Insurance City, State, Zip
Insurance Phone Number
Policyholder Name
Relationship to Patient
Group Name / Number
Medicaid Information
Type of Medicaid
Medicaid ID Number
Type Full Name Date
  
Please type the code to the box provided to prevent spam.



By pressing the "submit form" button above, I acknowledge that all information is true to the best of my knowledge

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Recommended Resources

SNApps4Kids

http://SNApps4kids.com/ - iPad, iPhone, iPod Touch, and Android apps for children with special needs.

 

 
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